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The nurse calculates the PaO /FiO ratio for the following values: PaO is 78 mm Hg; FiO is 2 2 2 2 6 (60%). What is the outcome and the relationship to the ARDS diagnosing criteria?
- A. 46.8; meets criteria for ARDS
- B. 130; meets criteria for ARDS
- C. 468; normal lung function
- D. Not enough data to compute the ratio
Correct Answer: A
Rationale: The correct answer is A: 46.8; meets criteria for ARDS. The PaO /FiO ratio is calculated by dividing the arterial oxygen partial pressure (PaO) by the fraction of inspired oxygen (FiO). In this case, PaO is 78 mm Hg and FiO is 0.6 (60%). Therefore, the calculation would be 78/0.6 = 130. This value is less than 300, which is indicative of ARDS according to the Berlin criteria. Choices B and C are incorrect as they do not align with the criteria for ARDS. Choice D is incorrect because the data provided is sufficient to compute the ratio.
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The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
- A. Continuously monitor heart rhythm.
- B. Check neurologic status every 2 hours.
- C. Place cooling blankets above and below the patient.
- D. Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
Correct Answer: D
Rationale: Correct Answer: D - Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
Rationale: LPNs/LVNs are trained to administer medications, including oral and nasogastric routes. Giving acetaminophen via nasogastric tube is within their scope of practice. LPNs/LVNs should have the knowledge and skills to safely administer this medication as part of the hypothermia protocol.
Summary of other choices:
A: Continuously monitor heart rhythm - This requires specialized training and skills typically within the scope of registered nurses or cardiac monitoring technicians.
B: Check neurologic status every 2 hours - Assessing neurologic status requires critical thinking and clinical judgment, which are typically responsibilities of registered nurses.
C: Place cooling blankets above and below the patient - Positioning and managing cooling devices may require specific training and should be done under the supervision of a registered nurse.
What must the patient must be able of in order to provide informed consent?
- A. Be capable of independent breathing.
- B. Have knowledge and competence to make the decision .
- C. Nod head to agree to the procedure.
- D. Both read and write in English.
Correct Answer: B
Rationale: The correct answer is B because informed consent requires the patient to have knowledge and competence to make a decision. This involves understanding the risks, benefits, and alternatives of the proposed treatment. Choice A is incorrect as it pertains to a physical ability unrelated to decision-making. Choice C is incorrect as consent must be verbal or written, not just nodding. Choice D is incorrect as consent can be obtained in various ways, not specifically through reading and writing in English.
A client with osteoarthritis is given a new prescription for a nonsteroidal anti-inflammatory drug (NSAID). The client asks the nurse, 'How is this medication different from the acetaminophen I have been taking?' Which information about the therapeutic action of NSAIDs should the nurse provide?
- A. Are less expensive.
- B. Provide anti-inflammatory response.
- C. Increase hepatotoxic side effects.
- D. Cause gastrointestinal bleeding.
Correct Answer: B
Rationale: The correct answer is B: Provide anti-inflammatory response. NSAIDs work by inhibiting the enzyme cyclooxygenase, thereby reducing inflammation, pain, and fever. This is different from acetaminophen, which primarily acts as a pain reliever and fever reducer but lacks significant anti-inflammatory properties.
Explanation of why other choices are incorrect:
A: Are less expensive - Cost is not related to the therapeutic action of NSAIDs.
C: Increase hepatotoxic side effects - While NSAIDs can have adverse effects on the liver, hepatotoxicity is not a primary therapeutic action of these drugs.
D: Cause gastrointestinal bleeding - While NSAIDs can increase the risk of gastrointestinal bleeding, this is a potential side effect rather than the primary therapeutic action.
A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes which interventions? (Select all that apply.)
- A. Administration of sedatives concurrently with neuromuscular blockade.
- B. Dangling the patient’s feet over the edge of the bed an d assisting the patient to sit up in a chair at least twice each day.
- C. Ensuring that deep vein thrombosis prophylaxis is initi ated.
- D. providing interventions for eye care, oral care, and skin care.
Correct Answer: C
Rationale: The correct answer is C: Ensuring that deep vein thrombosis prophylaxis is initiated. When a patient requires neuromuscular blockade for increased intracranial pressure, they are likely immobile, which increases the risk of deep vein thrombosis (DVT). Initiating DVT prophylaxis, such as compression stockings or anticoagulant therapy, helps prevent blood clot formation.
Choice A is incorrect because sedatives can mask signs of neurologic deterioration in this patient population. Choice B is incorrect as it promotes activities that may increase intracranial pressure and could be harmful. Choice D, while important for overall patient care, is not directly related to the specific nursing interventions required for a patient receiving neuromuscular blockade for increased intracranial pressure.
The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool (CPOT). Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
- A. Absence of vocal sounds
- B. Fighting the ventilator
- C. Moving legs in bed
- D. Relaxed muscles in upper extremities
Correct Answer: B
Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.